November 2018


EyeWorld/ASCRS reports from the 2018 ESCRS Congress

EyeWorld/ASCRS reports from the 2018 ESCRS Congress, September 21–26,
Vienna, Austria

View videos from the 2018 ESCRS:

Warren Hill, MD, discusses the artificial intelligence model for the Hill-RBF formula.

View videos from the 2018 ESCRS:

Renato Ambrosio, MD, PhD, discusses methods of screening for ectasia using biomechanics and imaging.

View videos from the 2018 ESCRS:

David Chang, MD, discusses posterior capsulorhexis and
anterior optic capture for premium IOL cataract cases in which there is a posterior capsular complication.

View videos from the 2018 ESCRS:

Nick Mamalis, MD, describes the progress in developing a
technology for IOL modification.

View videos from the 2018 ESCRS:

Thomas Samuelson, MD, discusses the CyPass and
guidance for moving forward with patients who have had the device implanted.

View videos from the 2018 ESCRS:

Oliver Findl, MD, discusses unique challenges in performing cataract and refractive phakic IOL surgery in the long eye.


Update on fungal keratitis

A session on the EuCornea program focused on the topic of fungal keratitis. Irina Barequet, MD, Tel-Aviv, Israel, discussed the clinical picture and diagnostics. 
Fungal keratitis, she said, is a continuously challenging condition and is an important cause of visual loss and even blindness. It requires a high level of suspicion, prompt diagnosis, and aggressive treatment, Dr. Barequet said, adding that the most common causative pathogens are filamentous fungi and yeasts.  
Dr. Barequet said the etiology varies geographically. It’s most common in tropical and subtropical areas. In the U.S., it makes up 5–10% of corneal infections, while in South India, fungi cause up to 47% of keratitis, and in Malaysia, it’s about 12–25%. 
The intrinsic virulence of fungi depends on the substances produced by the organism and the generated host response, Dr. Barequet said. The organisms that infect preexisting epithelial defects belong to the normal microflora of the conjunctiva and adnexa. 
Symptoms may include a slow initial course, manifesting 24–48 hours following the initial incidence of contact. Other symptoms include foreign body sensation, increasing eye pain, and photophobia. There are fewer inflammatory signs and symptoms during the initial period than with bacterial keratitis, Dr. Barequet said.

Glaucoma Day at ESCRS

Kicking off a morning of thought-provoking presentations was Fotis Topouzis, MD, Thessaloniki, Greece, who discussed the current glaucoma burden, remarking that 50% of OAG is undiagnosed in developed countries. In 2013, POAG was diagnosed in 5.36 million individuals in Europe and is estimated to rise to 6.39 million by 2040. 
Despite the rising numbers of glaucoma patients in our aging population, treating people who actually need help was the theme of a talk given by Anja Tuulonen, MD, PhD, Tampere, Finland. Aging alone increases yearly health costs by 1%, making it impossible to do everything for everybody with the resources at hand. It is crucial to stratify patients by risk and stop treating those who are largely glaucoma-free. 
Identifying risk factors for disease progression was a topic of discussion with IOP at its core, however, IOP does not explain everything, said Gordana Sunaric-Megevand, MD, Geneva, Switzerland. Nevertheless, lowering IOP reduces the risk of glaucoma progression and remains pivotal in any discussion about the disease. IOP shows dynamic patterns, with diurnal and body/head position-related fluctuations that are unrelated to patient age or glaucoma stage. Clinicians should use office hour supine IOP to predict night IOP and prescribe prostaglandins to reduce postural IOP changes. 
High myopes need to be carefully considered for glaucoma, according to a talk by Christoph Faschinger, MD, PhD, Graz, Austria, who thinks that “highly myopic eyes have glaucoma as long as the opposite has not been proven.” Current diagnostic tools cannot accurately differentiate changes shared by both high myopia and glaucoma. He recommends drops in highly myopic patients as the side effects are negligible compared to the benefits of the pressure-leveling effects. 
Augusto Azuara-Blanco, PhD, Belfast, U.K., discussed the use of peripheral iridotomy as more of a comfortable habit. He said that implementation failures persist in clinical medicine due to our difficulty in letting go of what we’ve learned will work. According to Anton Hommer, MD, Vienna, Austria, even trabeculoplasty has come under scrutiny in the face of newer, more effective glaucoma medications. Laser treatment remains a reliable option for clinicians, however, as drops lose efficacy over time. First and second SLT and ALT applications are predictable, with third and fourth applications largely ineffective. Arguments in favor of initial laser include IOP-lowering effects like monotherapy, higher safety than medication and surgery, cost effectiveness, and better efficacy than secondary laser. 
Andrey Brezhnev, MD, Kursk, Russia, maintained that traditional glaucoma surgeries achieve good hypotensive effects but are associated with intense postoperative care and carry the threat of vision-threatening complications. New technologies, such as MIGS, demonstrate acceptable clinical results and safety profiles but require randomized controlled trials and real-world observational studies. Combined cataract surgery/MIGS has an overall safety profile similar to cataract surgery alone, and cataract alone reduces IOP effectively as well as the reliance on drops for up to 3 years. However, combined surgery means one procedure, one recovery period, and less anesthetics. Standalone MIGS lacks long-term data, study standardization, cost effectiveness data, and has incomplete knowledge of ideal patient selection. 

Pharmacological prophylaxis in myopia

Donald Tan, MD, Singapore, highlighted studies looking at myopia and using atropine. He first said that interventional approaches to reducing myopia progression include spectacles, contact lenses, and pharmacological agents. 
Dr. Tan focused his presentation mostly on the ATOM1 and ATOM2 trials, which used different doses of atropine. ATOM1 used 1% atropine vs. placebo in 400 children over 3 years and ATOM2 used different lower doses in 400 children over 5 years.
Atropine was originally used to effect accommodation paralysis, and this led to the idea that it could reduce myopia. Atropine 1% eye drops have been available for over 40 years, however, the exact mode of action in myopia control is still uncertain. Atropine also has some ocular and systemic side effects.
Dr. Tan went on to describe ATOM1, which was a randomized, double-masked, placebo-controlled study to assess the safety and efficacy of atropine treatment in controlling myopia in children. It was initiated in 1999, and the study closed out in 2004. The treatment group received 1% atropine. It was a 3-year study, with 2 years of treatment and 1 wash-out year.
The bottom line, Dr. Tan said, was that, after 2 years of treatment, we proved that it worked. There was a 77% reduction in mean progression of myopia and strong correlation with axial length. However, in year 3, there was significant rebound of myopia progression upon cessation of atropine 1% eye drops. 
The problem with ATOM1 was the side effects, Dr. Tan said, so the ATOM2 study was undertaken to look at three lower doses of atropine (0.5%, 0.1%, and 0.01%). This study included a treatment phase of 2 years and a wash-out year. After the wash-out year, atropine was started again for those children whose myopia had started to progress again; they were put on atropine for another 2 years, with the 0.01% atropine dose. 
Dr. Tan noted that it appears that 0.01% atropine is clinically similar to 0.1%, 0.5% and 1.0% in efficacy in the studies. 
In ATOM2, the rebound phenomenon was present only in higher does, and 0.01% atropine had no rebound, and in fact, ended up with the lowest axial elongation. 
As far as the safety data for ATOM1 and ATOM2, the most common adverse side effect was allergic conjunctivitis. There was no loss of BCVA; glare was 1% (which was recovered on cessation of drops); there was no change in IOP; there was no cataract formation; and there was no loss of accommodation or permanent pupil dilation after cessation of drops.
Dr. Tan noted the percentage of children in ATOM2 who continued to have progressive myopia after the wash-out period related to the original concentration of atropine used in Phase 1: 68% progressed in the 0.5% atropine group, 59% progressed in the 0.1% atropine group, and 24% progressed in the 0.01% atropine group. 
Based on the ATOM trials, Dr. Tan said that we have learned that atropine eye drops effectively reduce myopia progression and axial elongation in children, even at very low concentrations, but a rebound phenomenon occurs with the higher doses of atropine. He said that atropine eye drops are safe, with no serious adverse events, but in the higher doses, the side effects of pupil dilation, loss of accommodation, and near vision limits practical use. He added that atropine 0.01% had the best therapeutic index, with clinically insignificant amounts of pupil dilation, near vision, and accommodation loss. Atropine 0.01% appears to retard myopia progression by over 50%, Dr. Tan said, and retreatment after a period of treatment cessation appears to be equally effective.

Challenging cornea cases

During an EuCornea focus session, presenters shared a variety of challenging cases and how they handled them. Carol Karp, MD, Miami, shared a challenging case of diagnosing a tumor. She discussed a 65-year-old white male who was referred for primary acquired melanosis (PAM). There were pigmented lesions straddling the limbus, and pigment adjacent nearby. What Dr. Karp particularly noted upon looking closer was subtle opalescence underlying the pigment on the cornea. 
Dr. Karp said that when encountering ocular surface squamous neoplasia (OSSN), you will find normal epithelium and an abrupt transition and thickened hyperreflective epithelium.
After taking a high-resolution anterior segment OCT for her patient, Dr. Karp did notice thickened hyperreflective corneal epithelium and an abrupt transition from normal to abnormal. She noted that this was a case of OSSN hiding in PAM.
Her next step was to biopsy the conjunctiva, which confirmed the OSSN and PAM diagnosis. Dr. Karp stressed that OSSN can often hide in other diseases, and the high-resolution OCT aided her in this case to identify it. She added that OSSN can be treated medically or surgically.

Finessing the application of crosslinking

The ESCRS/EuCornea symposium on corneal crosslinking invited renowned speakers to update delegates on some of the newest, most influential crosslinking studies. Theo Seiler, MD, PhD, Zurich, Switzerland, clarified the technical aspects of the procedure. Shorter operation times are achieved by increasing the irradiance from 3mW/cm2 up to 15mW/cm2 without any loss of efficacy, and the application of riboflavin in HPMC solution shortens imbibition time from 30 to 10 minutes. Oxygen flow over the cornea creates strong superficial crosslinking, however, good data is lacking. Switching UV light on and off does not increase efficacy, he said.
In the long term, custom crosslinking will produce a greater response than standard crosslinking, said Cynthia Roberts, PhD, Columbus, Ohio. She said that the primary corneal alteration is focally biomechanical, and the future will lead to the ability to predict curvature changes that result in visual improvements for patients, based on initial biomechanical measurements. 
In a presentation on topography-guided crosslinking, Francois Malecaze, MD, Toulouse, France, showed evidence of its safety and efficacy in the treatment of progressive keratoconus. It is currently the most adapted solution for customized treatments. Improvements are expected with transepithelial riboflavin solution and oxygen saturation.

Controversies in cataract and refractive surgery

The JCRS symposium explored controversies in cataract and refractive surgery. Topics included intraoperative OCT for the anterior segment, cataract surgery and corneal transplantation, and corneal refractive surgery.
Theo Seiler, MD, PhD, Zurich, Switzerland, argued that the best corneal refractive outcome is after PRK (surface ablation). In comparing LASIK and surface ablation, he noted that with surface ablation, you can save tissue. But he did add that rehabilitation/visual recovery with surface ablation takes longer. The ranges of treatment are similar for both procedures, he said.
Eric Donnenfeld, MD, Rockville Centre, New York, argued that the best outcome is after LASIK. He shared a number of studies looking at outcomes with the two procedures. While Dr. Donnenfeld admitted that the visual outcomes may be similar following LASIK and PRK, he noted the potential for corneal haze following PRK. He also highlighted the comparison of safety with LASIK and PRK, and he said that the “one differentiating factor” was the risk for infection. He noted that in a study of more than 300,000 eyes, the risk of infection was five times greater with PRK than with LASIK. PRK has a higher risk of corneal ulceration and scarring, he added.
Dr. Donnenfeld concluded by saying that LASIK is the safest, most successful, and most studied elective procedure in the world. LASIK results have continually improved as technology and surgical techniques advance and preoperative diagnostic screening and patient selection become more refined.

Ridley Medal Lecture

Rudy Nuijts, MD, PhD, Maastricht, the Netherlands, presented the Ridley Medal Lecture on “Facts First!” He highlighted the shift to “evidence-based medicine.” 
He discussed evidence relating to several topics in ophthalmology: toric IOLs, the PREMED study, endothelial cell loss and phakic IOLs, and endothelial keratoplasty. 
Dr. Nuijts shared studies on how toric IOLs perform in relation to monofocals, marking with toric IOLs, and cost effectiveness.
He also detailed results from the PREMED study, which looked at preferred preventive treatment of macular edema in non-diabetic and diabetic cataract patients. 
Dr. Nuijts shared results from a study looking at endothelial cell loss with iris-fixated phakic IOLs. He described a prospective, clinical cohort study to evaluate the long-term change in ECD in a total of 507 eyes of 289 patients receiving the Artisan myopia and Artisan toric iris-fixated phakic IOL (Ophtec, Groningen, the Netherlands). Dr. Nuijts noted that the patient cohort was unique in this study because the same protocol and same specular microscope were used for longer than 10 years of follow up. 
EC loss from 6 months to 10 years postoperatively was 16.6% in the myopia group and 21.5% in the toric group. Risk factors for increased EC loss included a shallow anterior chamber depth and a smaller distance between the central and peripheral phakic IOL edge to the endothelium. 
Dr. Nuijts shared data on the explantation rate with iris-fixated phakic IOLs and said that the explantation rate of the phakic IOL after 10 years was 1% in the myopic group, and the total explantation over the complete follow-up was 6% in the myopic group. 
Finally, Dr. Nuijts shared research examining if DMEK is better than ultra-thin DSAEK. In a trial he did in the Netherlands, he said there was no significance difference in visual acuity between DMEK and ultra-thin DSAEK. He thinks there are some indications that DMEK is better, but complications still seem to be higher with DMEK.

Glaucoma for cataract surgeons

Glaucoma specialists convened to deliberate on the present and future of glaucoma treatment. 
Understanding the trabecular meshwork is a crucial first step, according to James Tan, MD, Los Angeles, who spoke on his work with two-photon imaging of the distal aqueous outflow system in mice. Outflow is pulsatile and synchronous with the cardiac cycle. The distal outflow tract is not inert or static but a dynamic system and is its “own type” of self-regulating vascular system. His work demonstrated that Schlemm’s canal has valves (like lymphatics), and the walls of the intrascleral plexus have smooth muscle lining (like blood vessels). Further research into this field will show whether these cells adapt post-surgically, what their effect is on MIGS outcomes, and whether they can be manipulated with drugs, among other things.
Thomas Samuelson, MD, Minneapolis, shared his expertise on MIGS, noting that the risk of glaucoma surgery should not exceed the disease risk and that retaining normal physiology when feasible is a priority. Dr. Samuelson exercises caution with high outflow, low resistance surgical options that may “steal” flow from physiological pathways and cause spikes in IOP. Deciding among canal, transscleral, or supraciliary approaches is not a simple matter of device label and disease severity. Although severity is important, it is only one factor along with compliance and tolerance with medications and most importantly, the likelihood and velocity of progression. 
Trabeculectomy is alive and well, according to a presentation given by Ingeborg Stalmans, MD, PhD, Leuven, Belgium. Still considered the “gold standard,” trabeculectomy continues to effectively lower IOP, and although there are fewer and less severe complications thanks to modern techniques, they continue to be a reality. Bleb surgery provides low-teen pressures but requires bleb management. Unfortunately, a one-size-fits-all approach to glaucoma management is not yet appropriate, she said.
New glaucoma drug groups and drug delivery systems were covered by Antonio Fea, MD, Turin, Italy, who reminded delegates that 50% of an eye drop is lost immediately upon installation, 80% with reflex tearing, and that less than 5% of an active topical drug reaches the aqueous humor. Nearly 90% of ophthalmologists would consider sustained-release options for medication application, while 55% of patients would prefer to stick with eye drops. Degrees of acceptance vary according to age, region of the world, availability, prices, reimbursement, and adverse events.

When cataract surgery goes wrong

A surgical video session featured a variety of ways to deal with cataract surgery when it goes wrong. 
Bernardo Feijoo, MD, Lisbon, Portugal, shared a case of a posterior polar cataract, noting that there is a high rate of complications with these types of cataracts. He advised the patient prior to surgery of the risk of complications. 
During the procedure, Dr. Feijoo noted that his first mistake was that he was trying to do a slow and smooth hydrodissection. It seemed that this technique was working, and he was trying to avoid rotating the nucleus. Dr. Feijoo proceeded with phaco, and it seemed as though everything was fine. He began using a traditional technique and tried to create a crease that was not very deep. The chamber seemed stable at this time, with no deepening. 
However, Dr. Feijoo did not achieve good separation between the epinucleus and endonucleus. He switched to using a blunt instrument because he was very near to the posterior capsule at this time, and it was then that he began to realize that things were not going very well. 
Dr. Feijoo realized that the capsule was probably broken. He retracted his instruments very quickly, causing the nucleus to drop.
After this, he tried to ensure that the anterior segment was free of vitreous. Dr. Feijoo said that he knew the patient would have to be referred to a retina specialist and the surgery would not be complete at the end of the operation. He used preservative-free triamcinolone to both ensure there was no vitreous coming forward and to help with inflammation in the postoperative period.
Dr. Feijoo said he proceeded by injecting the IOL into the ciliary sulcus. This may be a controversial choice, he admitted, but if it’s in place, it ensures some separation between the anterior and posterior chamber.
After showing the case, Dr. Feijoo stressed the importance of avoiding hydrodissection in these cases. Now, he prefers to use hydrodelineation.

The many sides of extended depth of focus

Beatrice Cochener, MD, PhD, Brest, France, opened the extended depth of focus (EDOF) symposium with a discussion of optical principles. EDOF are designed to provide a range of visualization rather than a single focal point and result from progress in optics and better understanding of vision quality. Dr. Cochener made the case for contrast sensitivity, explaining that stretching the visual range would ultimately come at the price of contrast.
Both additive and subtractive technologies can result in an EDOF cornea, according to a presentation given by Roberto Bellucci, MD, Verona, Italy. Corneal inlays are indicated unilaterally and are more difficult to center than presbyLASIK, requiring closer follow-up. PEARL (PrEsbyopic Allogenic Refractive Lenticule) is a promising technique to achieve an EDOF cornea. Bilateral presbyLASIK techniques are “heavier” in the non-dominant eye and have good published results. Dr. Bellucci explained that selecting the appropriate procedure should be tailored to the patient’s character and needs, however, bilateral asymmetric central presbyLASIK is his preferred approach.
Another option that has been successfully implemented to extend the depth of focus is the use of the small aperture IC-8 IOL (AcuFocus, Irvine, California). Discussing his experience with this technology, Burkhard Dick, MD, PhD, Bochum, Germany, noted that small aperture IOLs reliably achieve this goal without splitting light. Visual acuity is excellent, and the lens can compensate for deviations in target refraction and residual astigmatism. These lenses give high quality distance vision and cause no change to binocular contrast sensitivity, he said. They also do not encumber retinal visualization, and patients are satisfied with the outcomes.
Monovision remains an excellent option to achieve spectacle independence and is not a “cheap multifocal,” according to Ehud Assia, MD, Tel-Aviv, Israel. The surgeon does not need to decide to carry through monovision during the first surgery, said Dr. Assia, who achieves optimal results with –1.75 D. He thinks that it is slightly less effective than multifocal IOLs but has fewer adverse effects and high patient satisfaction. His overall personal approach involves: trifocals if the patient desires spectacle independence, although photopic phenomena are expected; EDOF or low monovision (about 1.0 D) if the patient wants spectacle independence with a priority for intermediate over near vision, or if the eye is not ideal; and he aims for emmetropia in the first eye, irrespective of dominance, if the patient does not want a MFIOL or is unable to afford one. When the UCVA is good, he recommends setting the second eye for near, even if the patient does not ask for near vision correction.

The capsulorhexis

The ESCRS Heritage Lecture was given by Thomas Neuhann, MD, Munich, Germany, and highlighted the invention and evolution of the capsulorhexis.
He looked back to techniques in the 1970s and 1980s. One critical step, he said, was the technique for anterior capsulectomies: can-opener, letter box, or Christmas tree. The can-opener was the most adopted because it opened the capsule in circular fashion and had a controlled diameter. 
The other critical element of modern cataract surgery at the time was where the posterior chamber lens would be implanted, Dr. Neuhann said. It would either be implanted in the ciliary sulcus (the most common) or into the capsular bag.
The turning point for Dr. Neuhann was when his mentor, Richard Kratz, MD, suggested a transition to in-the-bag implantation but the current technique, can-opener, proved to be an obstacle to this. Dr. Neuhann realized he would either have to find a solution or stay in the sulcus. 
Dr. Neuhann began to explore different techniques, visiting renowned capsular bag implant surgeons. Theoretical considerations were important. The lens capsule is comparable to cellophane, so a continuous anterior capsular margin, closed in itself, would be a solution.
A case he encountered in the fall of 1984 spurred him to produce his capsulorhexis technique because the can-opener technique failed for his patient with retinitis pigmentosa because her zonules were so loose. 
Howard Gimbel, MD, was working on a similar principle at the time. Dr. Neuhann stressed that the term “capsulorhexis” refers to the technique and the process “to tear” rather than cutting. 
He added that it’s now recognized that he and Dr. Gimbel “invented” the basic principle simultaneously and independently from each other, using technical approaches somewhat different in detail. Dr. Neuhann said that the technique used today of the circular capsulorhexis is based on his variant of the common basic principle and first described in scientific literature.

Video symposium on surgical complications

In a video symposium, Michael Amon, MD, Vienna, Austria, shared a case of a late onset Argentinian flag. The patient had a mature white cataract with a 4+ nucleus, and Dr. Amon put trypan blue under OVD. Early in the case, Dr. Amon encountered a partial radial tear of the anterior capsule.
He questioned the audience how they would proceed with a partial radial tear. While 26% said they would proceed and ignore the radial tear and 11% said they would remove the instrument and complete the CCC, the majority (63%) said they would stay with the tip, inject OVD, and complete the CCC. 
However, in this case, Dr. Amon noted that he removed the instrument, which resulted in a total tear. 
Dr. Amon then asked how the audience would proceed with a total radial tear. Responses were split more evenly, with 28% indicating they would do ECCE, 20% would do supracapsular phaco, 22% would choose divide and conquer, 24% would chop, and 6% would divide oblique to the tear. Dr. Amon said he chose to divide oblique to the tear. He rotated the lens and broke the hard nucleus in an oblique position.
Panelist Dr. Bellucci noted that a radial tear may be able to be left alone without extending to the posterior capsule, if you are in good control of the fluidics. 
When asked which IOL position and type they would choose in this scenario, 52% of audience members said they would pick a one-piece hydrophobic IOL in the bag. Meanwhile, 27% would choose a three-piece lens in the sulcus, while only 5% would choose a one-piece hydrophilic IOL in the bag. 
Panelist Stefan Mennel, MD, Feldkirch, Austria, indicated that he would choose to do a three-piece lens in the bag, while Dr. Bellucci said he would choose the one-piece hydrophobic IOL (being sure to open the lens slowly). He noted that the hydrophilic IOL may not be a good option in this case because a hydrophilic lens tends to open quickly, which could disturb the anatomy of this capsule.
Dr. Amon indicated that he chose a hydrophobic one-piece lens with slow and gentle unfolding. 
Finally, to handle the capsulorhexis, Dr. Amon said he removed OVD and rotated the haptic to 90 degrees; 61% of the audience indicated this is how they would have handled this case.
Dr. Mennel added that you have to be careful because there could be a risk of rupture of the posterior capsule. 
Before closing, panelists also revealed whether they think a multifocal or toric lens would be a contraindication in this case. Dr. Bellucci said he thinks a toric is contraindicated, and he said he may do a multifocal if it was the second eye, but not in the first. Dr. Mennel said he would not use a toric or multifocal lens in this case.

Best solutions for high ametropia

Refractive surgery specialists convened at a symposium for an informative exchange of perspectives about risky, borderline patients. 
Corneal refractive surgery and cataract surgery can both disrupt the eye’s natural compensation for aberrations, according to Pablo Artal, MD, Murcia, Spain, who spoke on optical and anatomical limitations. In comparing phakic IOLs (pIOLs) with LASIK, he noted that the measured optical performance of pIOLs is slightly superior to LASIK but less than predicted from corneal data. Retinal images also show a slight edge in favor of pIOLs. Ablation profiles and pIOLs would improve outcomes in patients, considering the particular optical characteristics of highly ametropic eyes. 
Corneal refractive surgical outcomes for high myopia (–6 to –10 SE) have improved. Jodhbir Mehta, MD, Singapore, said that high myopes are at a significant risk for unwanted side effects like severe dry eye and HOA induction, but many of these patients already have preoperative issues with aberrations from glasses and contact lens wear. Specialists should be aware of associated retinal pathologies, and for very high myopia, Dr. Mehta recommends ICL implantation.
Oliver Findl, MD, Vienna, Austria, discussed intraocular surgery in the long eye, saying that while refractive pIOL outcomes are excellent, the key to pIOL selection should take complications into account, as explantation is a definite scenario in most cases. In long eyes, options for treatment include phakic IOLs and RLE, with which retinal detachment is a main issue, as well as the fact of inducing presbyopia in younger patients. In the ongoing MYOPRED ESCRS study, Dr. Findl is investigating the influence of posterior vitreous detachment on retinal detachment in lens surgery in myopic eyes. The multicenter, international study has currently enrolled 618 patients with axial lengths in excess of 25.0 mm and will include a 5-year follow-up.
Short eyes are different, according to Boris Malyugin, MD, PhD, Moscow, Russia, who reminded delegates of the distinction between nanophthalmos, microphthalmos, and relative anterior microphthalmos. He said that complications resulting from lens-based surgery in micro- and nanophthalmic eyes was 15.5%, but those seen in nanophthalmic eyes (axial length below 20 mm) reached 42.9% of cases, with severe complications noted in 23.8%. He highlighted careful preoperative evaluations and IOL power calculations.
Surgery in highly hyperopic eyes is “an expert’s job only,” according to Walter Sekundo, MD, Marburg, Germany, who argued in favor of corneal lamellar surgery, not surface ablation, in select cases. He performs the treatment of high hyperopia (+3.0 D to +6.0 D) by means of corneal refractive surgery, including an extensive preoperative diagnostic work-up. Expected LASIK outcomes from the literature show that roughly 70% of high myopes are within 1.0 D, with a 10–20% loss of one line of Snellen, a 6% loss of two lines or more, and retreatment rates up to 10%. Refractive results for high hyperopia with SMILE seem to be similar to LASIK.
Jesper Hjortdal, MD, Aarhus, Denmark, thinks that high astigmatism of more than 6 D and post-PK astigmatism should be treated with arcuate keratotomy, while high astigmatism of up to 5 D can be treated via PRK, LASIK, SMILE, or toric IOLs. Irregular astigmatism requires topography-guided ablation and can also be addressed with the use of intracorneal ring segments. Dr. Hjortdal noted that he always keeps track of the right meridian.

CSCRS symposium

The Combined Symposium of Cataract and Refractive Societies (CSCRS) covered the topic of “Current Debates in Ophthalmology.” 
Juan Mura, MD, Santiago, Chile, spoke about how bilateral cataract surgery is “the way to go.”
He shared some of the pros and cons of performing the procedure bilaterally. First, he said that one of the main benefits from the patient perspective is faster visual rehabilitation. Additionally, patients can avoid anisometropia between surgeries, can have fewer postop visits, less transportation is necessary, and there is less need for accompanying family members. 
Dr. Mura added that there are also benefits of bilateral surgery for the hospital and health system. For the hospital, there is only one admission and it’s more efficient for OR time. For the health system, it offers shorter waiting lists and is cost effective. 
However, he did note some cons of bilateral surgery, including risk of endophthalmitis, TASS, and ocular hypertension (these can occur early). Late bilateral complications include refractive surprise, cystic macular edema, and corneal decompensation. There may also be financial barriers for facilities and surgeons with a bilateral procedure. 
On the other side of the topic, Myoung Joon Kim, MD, Seoul, South Korea, questioned if bilateral cataract surgery is the way to go. He prefers to do delayed sequential cataract surgery. The greatest fear is bilateral simultaneous endophthalmitis, he said. TASS and corneal edema are also concerns.
Although the prevention and treatment methods of endophthalmitis have improved, the risk still exists, Dr. Kim said. He added that there are both patient factors (immunity, blepharitis, and habits) and device factors (manufacturing, cleaning, and sterilization) that could affect both eyes.
Dr. Kim said that on the surgeon side, benefits of an interval between cataract surgeries include prevention of complications, IOL selection, and customized advice. On the patient side, they can prepare mentally and physically between surgeries. 
Also during the session, Sri Ganesh, MD, Bangalore, India, and Terry Kim, MD, Durham, North Carolina, debated if SMILE is better than LASIK.
Dr. Ganesh argued in favor of SMILE, mentioning some of the disadvantages of femto LASIK: flap-related complications, loss of sub-epithelial plexus leading to dryness, integrity of corneal biomechanics is breached, relatively more time consuming, and minor patient discomfort. 
Meanwhile, Dr. Kim highlighted the high satisfaction with the LASIK procedure. He also mentioned some of the limitations of SMILE, including some safety concerns, ability to do enhancements, and the fact that it is only currently approved in the U.S. for spherical myopia. 
On the topic of “Intracameral prophylaxis should be mandatory,” Eric Donnenfeld, MD, Rockville Centre, New York, argued that it should be mandatory. 
He highlighted studies demonstrating how the use of intracameral prophylaxis has reduced the rate of postoperative endophthalmitis following cataract surgery. He mentioned studies by ESCRS, the Aravind Eye Hospital in India, and more, which compiled thousands of cases to show reduction in the endophthalmitis rate using cefuroxime, moxifloxacin, vancomycin, or some combination of these. 
It is about time intracameral antibiotics are approved in U.S., Dr. Donnenfeld said, mentioning the Topical versus Intracameral Moxifloxacin for Endophthalmitis prophylaxis (TIME) study, which is currently underway and seeks to show that intracameral moxifloxacin is superior to topical moxifloxacin for the prevention of postoperative endophthalmitis. 
If the study hypothesis is proven, Dr. Donnenfeld said, this will provide additional prospective evidence for the use of intracameral antibiotics. 
On the other side of the topic, Antoine Brezin, MD, Paris, France, discussed why intracameral prophylaxis should not be mandatory. 
Dr. Brezin argued that while there has been a reduction in the rate of endophthalmitis worldwide, many factors have changed, and this may not be directly related to intracameral medication. 
Other factors influencing endophthalmitis, he said, are that the duration of surgery has been reduced, machines have improved, surgical theater air filtering systems have improved, incision size, IOL material, and preloading vs. manual folding, among others. 
Dr. Brezin said he uses intracameral prophylaxis, but he chooses it more because of the “fear factor” rather than because of the science behind it.

EyeWorld/ASCRS reports from the 2018 ESCRS Congress EyeWorld/ASCRS reports from the 2018 ESCRS Congress
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